Questions to Ask Patient
Questions for clinicians taking a history: what the person came in for, how the problem behaves, what they are already taking, what they are afraid of, and what they want out of the visit. Written as a prompt list for the consultation itself, not as clinical guidance.
The questions
Open any question for the note
What brings you in today?
Why ask it
Open it and then stop talking. Most patients finish their opening account in under a minute if they are not interrupted, and the detail that turns out to matter is often in the second or third sentence rather than the first.
Is there anything else on your list for today?
Why ask it
Asked at the start, this catches the second and third problem before you have committed the appointment to the first. The item raised in the last two minutes of a visit is often the one the patient came for.
Tell me about it from the beginning, in your own words.
Why ask it
A narrative gives you onset, sequence, and what the patient links it to, which a checklist of closed questions will not. If the story starts with a specific day or event, that anchor is usually reliable; if it fades into always, the timeline needs pinning down separately.
Where is it, and what does it feel like?
Why ask it
Site and character in the patient's own words are worth more than your paraphrase, so record the phrase they use. Patients who point rather than describe, or who use a whole hand rather than a fingertip, are telling you something about how localized it is.
What makes it better, and what makes it worse?
Why ask it
Position, food, movement, rest, time of day, and medication all show up here. The relief factors matter as much as the aggravating ones, and an answer of nothing changes it is itself a finding worth noting.
Where would you put it now on a scale of zero to ten, and where does it get to at its worst?
Why ask it
Two numbers are more useful than one, since a patient sitting comfortably at three may be reporting a condition that reaches nine at night. Ask what number would be acceptable to them, because that is the target you will be measured against.
What have you already tried for it?
Why ask it
Ask explicitly about things they bought themselves, borrowed, or found online, since patients often do not count those as treatment. What failed narrows the differential, and what helped briefly is often the most informative answer.
What have you had to stop doing because of this?
Why ask it
Function tells you severity more reliably than a pain score. Concrete losses such as stairs, sleep, driving, or work give you something measurable to recheck at the next visit.
What do you think is going on?
Why ask it
Patients almost always have a theory, and it explains why they came in now rather than a month ago. It also lets you correct a specific fear rather than reassure in general, which rarely works.
What worries you most about it?
Why ask it
Often quite different from the presenting complaint: a relative who had the same symptom, a fear of losing work, a scan result someone mentioned. Address the named worry directly or the patient will leave unsatisfied regardless of the clinical outcome.
What medicines are you taking, including anything over the counter or herbal?
Why ask it
Naming the categories catches what a general question misses: supplements, painkillers, sleep aids, eye drops, inhalers used rarely, and someone else's tablets. Asking them to describe the packet or bring it in resolves more than a list from memory.
Are you able to take them the way they were prescribed?
Why ask it
Phrased as a question about ability rather than compliance, this gets honest answers about cost, side effects, swallowing, and forgetting. A patient whose blood pressure is not controlled on three drugs may simply not be taking two of them.
Have you ever had a bad reaction to a medicine, and what happened?
Why ask it
Ask what happened rather than accepting the word allergy, because nausea, a family story, and anaphylaxis get recorded identically and one of them closes off a whole drug class unnecessarily. Note the year if they remember it.
What conditions have you been diagnosed with, and what operations have you had?
Why ask it
Two prompts rather than one, because patients frequently omit surgery when asked about medical history and omit long-standing conditions they consider settled. Anything they mention with a date attached is usually accurate.
Has anyone in your family had anything like this?
Why ask it
More productive than asking for a general family history, since it directs attention at the current problem. Follow with whether anyone died young or unexpectedly, which patients rarely volunteer but usually remember clearly.
Do you smoke, drink, or use anything else, and roughly how much?
Why ask it
Ask in a flat tone with the amount attached, since a yes or no answer is close to useless. Quantifying by a typical week rather than a typical day tends to produce a more accurate figure, and asking what a heavy day looks like adds more.
What do you do for work, and does it make this better or worse?
Why ask it
Exposures, repetitive movements, shift patterns, and the risk of losing income all sit behind this. The second half also tells you whether a treatment plan requiring rest is realistic for this person.
What else has been going on in your life while this has been going on?
Why ask it
Leaves room for bereavement, a job loss, caring responsibilities, or a relationship ending without labelling any of it as stress. What comes out here frequently changes how the presenting symptom should be understood.
Who is at home, and who helps you when you are unwell?
Why ask it
This determines what is safe to send home. Answers involving no one, or a partner who is also unwell, matter for discharge planning, follow-up, and any treatment requiring supervision.
What would a good outcome from today look like to you?
Why ask it
Patients often want something narrower than you assume: a note for work, a name for the problem, permission to stop a drug, reassurance about one specific thing. Knowing it lets you say plainly whether it is achievable today.
How much do you want to know about what we find?
Why ask it
People differ widely in how much detail and how much uncertainty they want, and this is best established before results rather than after. Ask also whether they want anyone else present or informed.
Is there anything I have not asked about that you want me to know?
Why ask it
Closing with an open door catches the symptom they were embarrassed to raise and the question they had written down. If the answer is substantial, treat it as a reason to extend the visit rather than defer it.
Taking a History
Practical guidance for the conversation itself
During the Consultation
Set the agenda before you start on problem one
Ask what else is on the list at the beginning rather than the end. Then say out loud what you can cover today and what will need another appointment. Patients accept a limit stated at the start far better than one imposed at minute twelve.
Let the opening account run
Resist the pull to convert the story into closed questions immediately. Silence, a nod, and anything else are cheap and often produce the detail that reframes the case. Save the systematic questioning for after the narrative is done.
Use their words in the notes
Record the phrase the patient used for the sensation rather than translating it into a clinical term straight away. Their wording survives handover better and stops an early hypothesis from hardening into a documented fact.
Ask about medicines with categories, not in general
Prescriptions, things bought at a pharmacy, vitamins and herbal products, creams and drops, inhalers, injections, and anything borrowed. Each prompt recovers items a single open question loses.
Check what they took away
Near the end, ask them to tell you in their own words what the plan is and what would make them come back sooner. This finds the misunderstanding while it can still be corrected, and it takes under a minute.
Common Pitfalls
- Interrupting the opening account to start a systems review. The interruption usually arrives before the patient has reached their main concern.
- Accepting the word allergy without asking what happened. Recorded intolerances remove drug options for years on the basis of a single episode nobody characterized.
- Asking whether they take their medication rather than whether they are able to. The first invites a yes; the second invites the reason.
- Taking a substance history in a tone that makes honesty costly. Flat delivery and a quantity in the question get closer to the truth.
- Treating a low pain score as a low-severity problem without asking about function or about the worst of it.
- Talking past a stated fear. If the patient is worried about cancer, a general reassurance that it is probably nothing does not reach the worry.
- Relying on a relative to answer for a patient who can answer for themselves. Ask the patient first and check whether they want the relative in the room.
Adjusting for the Situation
- Short appointment: the agenda question, the narrative, function, medicines, and what they are worried about will cover most of what changes management.
- Follow-up visit: start with what has changed since last time and whether the plan was workable, rather than repeating the full history.
- Interpreter present: speak to the patient, keep sentences short, and expect the visit to take longer. Family members should not be used as interpreters for sensitive content.
- Cognitive impairment or a very unwell patient: gather what you can from them directly, then corroborate with a carer, and record which information came from whom.
- Sensitive subjects: say why you are asking and who will see the answer before you ask. Permission and purpose raise the accuracy of the response.
- Adolescents: offer part of the consultation without a parent present, and be explicit about the limits of confidentiality before they answer anything.